Citing low demand, high costs and questioning the benefits, Utah's Southwest Public Department of Health does not stock or recommend Gardasil, the vaccine against HPV, the cancer-causing human papilloma virus.
The decision to exclude the vaccine from its public health clinics in Beaver, Iron, Garfield, Kane and Washington counties was made years ago, not by the area's Board of Health, but by the agency's director, physician David Blodgett.
"The backlash and sentiment against it was strong enough that there's no reason to go there," Blodgett explained. "No one wants it and it's too expensive when we're not funded to provide it."
But in light of Utah's dismal HPV vaccination rate, Blodgett's decision is stirring new debate in public health circles.
The vaccine isn't mandated in Utah. But the Utah Department of Health has been recommending it for preteen girls since 2006, and for boys since 2011.
At 42 percent, Utah ranks lowest in the nation for completion of the three-injection series among girls who start it. The national rate is 71 percent, according to the National Immunization Survey. There isn't enough data on boys to publish.
Reasons for the slow uptake are varied, including concerns that giving the vaccine at such a young age, by 11 or 12, is a license to be promiscuous which research has disputed, said William Cosgrove, a pediatrician in Murray and a member of the Utah Scientific Immunization Advisory Committee.
For a senior health official to downplay the benefits of a life-saving vaccine is "highly unethical," said Cosgrove.
Gardasil is safe and more than 95 percent effective at preventing four sexually transmitted viruses responsible for 70 percent of cervical cancer and 90 percent of genital warts, he said. It's also proven effective at preventing throat, penile and anal cancers.
"Adolescents face an 80 percent chance of being infected by one or more of these viruses," said Cosgrove.
The three-shot series can retail for $360, but is fully covered by private insurance and provided free of charge to low-income families and public health clinics through the federal Vaccines for Children program.
"To be dissuaded by cost issues, or to not stock the vaccine due to low public demand, is disingenuous, especially for someone with responsibilities to protect the public," said Cosgrove. "I believe the real medical issues here are clouded by a moralistic belief system that precludes any frank discussion about sexuality in adolescents."
Blodgett cites other problems with Gardasil, namely that it was fast-tracked through the Food and Drug Administration (FDA) and a belief that its benefits were oversold by drug maker Merck.
"The science wasn't good... We had physicians in our community arguing that we not make it available," said Blodgett.
HPV is "absolutely a risk for cervical cancer," but it's not the only risk, he said, arguing the vaccine cuts risk by 17 percent. Cancers caused by HPV are extremely rare and immunization comes with no guarantee for long-term protection; women are still supposed to get regular Pap smears to test for the virus, he said.
Weighed against the vaccine's risks, "the public isn't buying it," he contends. "It's eroding public trust in immunization programs."
TriCounty Health Department, spanning Daggett, Duchesne and Uintah counties, makes the vaccine available only with a doctor's prescription.
"It's a complicated vaccine that requires discussion about [sexual health] and a physical exam and follow-up visits with a doctor," said the agency's director, Joseph Shaffer. "My feeling is that's better held in the physician's office than here at the health department."
Fear that Gardasil is dangerous hasn't been eased by the FDA's assurances. The agency approved and monitors the drug and says its safety profile matches those of other vaccines.
Earlier this week, national talk show host Katie Couric featured a woman on daytime TV who said the HPV vaccine killed her daughter. The show was roundly criticized by other media, including Slate and Forbes magazines.
Residents of southern Utah still have access to Gardasil through private clinics. But like all drugs, the vaccine has an expiration date. Cosgrove said many rural doctors can't afford to keep it stocked, creating an access problem.
Southwest's decision has ripple effects for the entire state, he said.
"When I choose not to vaccinate, I'm making decisions that affect the health and safety of strangers down the line," he said. "No one really talks about that cascade of responsibility."
Each year in America there are an estimated 26,000 new cancers attributable to HPV, according to the U.S. Centers for Disease Control and Prevention.
That's in addition to nearly 2 million cases of high- and low-grade cervical dyplasia, or precancerous cells, and 360,000 new cases of genital warts a year.
"We have a vaccine to prevent that heartache," said Cosgrove. "Yet we have parents and doctors who don't want to face it and a public health association that is wishy-washy at best."
Demand for Gardasil, or the HPV vaccine, varies across Utah. The vaccine offers the best protection to girls and boys who receive all three doses by age 11 or 12, in time to develop immunity before they become sexually active, federal health officials say.
Southwest Utah Public Health Department (Beaver, Iron, Washington, Garfield and Kane counties)
10.9 percent of youth between ages 12 and 17 had received one dose of the three-dose vaccine as of 2012; 6.7 percent had received two doses and 4.2 percent had received three doses.
Salt Lake County Health Department
17 percent of youth between ages 12 and 17 years of age had received one dose of the three-dose vaccine; 11.1 percent had received two doses; and 7.3 percent had received three doses.